Perforated peptic ulcer (PPU) is developed in 2%–10% of peptic ulcer [1]. PPU is common emergent condition that requires emergency surgical treatment. When a perforation occurs, chemical peritonitis including sudden-onset severe abdominal pain, tachycardia and abdomen rigidity were induced. Delay of diagnosis and proper treatment in PPU result bacterial peritonitis and that each hour from onset symptom of PPU increase mortality by 2.4% [2].

The short-term overall mortality of PPU is reported as high as 30% and the morbidity is reported 50% [1,3,4].

Although non-operative treatment or spontaneous resolution was adopted in some perforations, the essential treatment is usually emergent surgical repair by laparotomy with or without omental patch.

Although the surgical repair with or without omental patch is popular and essential method, the various surgical methods including omental plugging, omental grafting or gastrectomy are adopted in various clinical conditions. However, the consensus remains unclear regarding the best surgical method for PPU [5,6].

In cases of LES for PPU, the laparoscopic surgical repair with or without omental patch is popular but other laparoscopic methods are rare in LES for PPU. Therefore, the LES for PPU means laparoscopic simple repair method with or without omental patch in most of published literatures.

In WSES guidelines, operative treatment recommended as soon as possible in PPU with significant pneumoperitoneum or signs of peritonitis [6].

The LES for PPU is increasingly being preferred with the innovation of laparoscopic devices and procedures and increase of surgeon’s expertise and experiences. This review summarizes current status about LES for PPU.

The LES have various advantages like as laparoscopic elective surgery [7]. Also, in PPU, the advantage in LES is similar. A recent meta-analysis with PPU has reported significant advantages of laparoscopic repair in terms of postoperative pain and wound infection.[8] However, no significant differences in the overall postoperative mortality, leakage, postoperative abscesses, and reoperation rates in stable patients were observed between laparoscopic and open surgery [1,6,8]. But, the mortality in LES for PPU is about 3.8%–13.6% that better than overall mortality (30%) in PPU [1,3,4,9–11].

Generally, a LES is recommended in stable patient. And, in selected patient with instability a LES may be adopted. The patient selection criteria is recommended in hemodynamic stability, surgeon’s skills, cardiovascular or pulmonary comorbidity and Boey score [6,10]. The Boey score is consisted 3 point factors including perforation duration, preoperative shock and concomitant severe medical illness (Table 1) [2,10,12].

An open approach is recommended in the absence of appropriate laparoscopic surgical skills and equipment. And in unstable patients with PPU, an open approach is recommended with low quality of evidence. A LES is recommended in stable patient with Boey score 0–1 [10].

In a United States retrospective study of minimally invasive emergency surgery procedures between 2007 and 2016, in 190,264 patients, the LES for PPU was performed in 1/3 of the patients [13]. In Korea, the LES for PPU was performed in 8% of 2,122 patients in retrospective study of 3 hospitals in Korea between 2014 and 2019 [7]. The rate of LES for PPU is not same from country to country (Table 2 [7,13–15]). These differences in rates of LES for PPU may be indicative of the variability in the healthcare infrastructure and patient-related factors between countries [7]. In Korea, surgical skill, access to laparoscopic facilities and infrastructure are better than a developing country, but several environmental factors may affect the LES rate for PPU. In the study by Bae et al [7], data was collected retrospectively from 3 tertiary hospitals where emergency surgery is typically assigned to a junior surgeon or an emergency duty surgeon. The assigned surgeon may not be specialized in LES for PPU and daily variability in LES skill exists. The LES rate for PPU is affected by surgeons’ preferences.

Whereas, in Korea community hospitals, the LES rate may be higher than tertiary hospitals because the surgeon may be well experienced (and previously well trained in tertiary hospital) in laparoscopic skill. Further study, including tertiary and community hospital data, is needed.

The surgeon’s decision to perform LES for PPU is affected by general, and patient-related, limiting factors (Table 3). Even surgeon’s fatigue, physical strength, level of stress, and poor emotional mood may affect the decision to perform LES. The performance of LES has been reported to be affected by various limiting factors [16,17]. These limiting factors can be categorized to 3 groups: (1) general limiting factors; (2) patient-related limiting factors; and (3) intraoperative limiting factors (Table 3). The general limiting factors include a surgeon’s skill, duty hours, and estimated surgical duration which may indicate a surgeon’s preferences, and level of stress. In emergency conditions, the tendency of a surgeon’s decision to perform LES is made by considering pre, intra, and postoperative safety and familiarity of procedure. Therefore, a surgeon who primarily performs elective surgery cannot be expected to perform LES (considering familiarity and safety of procedure). An acute care surgeon who is well-trained in laparoscopic skills is the appropriate surgeon to perform LES for PPU [13,18–21].

Despite applying the clinical decision criteria, a surgeon’s preferences, and limiting factors to indicate the use of LES, the conversion risk to open surgery exists. The conversion rate has been reported in a Korean, and an Italian study to be 10.4%–52.7% [9,11]. Practically, the reasons for conversion to open surgery are reported to be difficulty in localization and a making operation field, inflammatory adhesion, large defect, suspected tumor, and friable tissue [9,11]. The risk factors for conversion to open surgery are previous laparotomies, a greater ulcer size and a posterior location of the ulcer [11]. The actual size and location of the ulcer is only revealed when exploration is performed, therefore, the diagnostic laparoscopy should be in the acute abdomen. Strictly, when the acute abdomen requires emergency exploration, the first approach is a diagnostic laparoscopy. In the operative view, during the diagnostic laparoscopy, the correct surgical procedure (according to disease) should be determined and performed. The consensus of the expert panel of the WSES, indicates a diagnostic laparoscopic approach in stable patients undergoing emergency abdominal surgery for general surgery emergencies [22].

Laparoscopic surgical skill and equipment continue to be developed and innovated. Traditionally, the repair technique for PPU is gastrorrhaphy which is performed using interrupted suture material (knotted) in open surgery and LES. However, knotless barbed suture materials (V-Loc™; Covidien, Mansfield, MA, USA, Stratafix™, Ethicon Endosurgery, Inc., Cincinnati, OH, USA) are now being used in gastro-intestinal surgery [23,24], including LES for PPU [5,25–27]. An educational video of LES for PPU, detailing the laparoscopic knotless suture repair using barbed suture material, was released in an open access format comparing between knotless and interrupted suture repair [28]. However, in the recent WSES guidelines for PPU, there was no description of LES knotless suture repair [6]. In retrospective studies, using data on LES for PPU, when comparing between knotless and interrupt suture repair, the results suggested that the laparoscopic knotless suture repair using barbed suture material was an alternative, feasible, safe, simple and non-inferior method [5,25–27]. The statistical difference in the mortality rate between laparoscopic interrupted stitches repair and knotless barbed suture is not significant (Table 4 [5,25–27]).

The single port laparoscopic surgery is an innovative surgical approach. However, the single port LES for PPU has only been studied as 4 case reports [29–32], therefore studies on the feasibility, safety, and clinical outcome need to be performed. The recommendation, based on the evidence, for using single port LES for PPU, is unclear.

LES for PPU has advantages over open emergency surgery in terms of postoperative pain and wound infection, although differences in LES rates and the surgeon’s decision to perform LES are present. This could be due to variability in the healthcare infrastructure and various limiting factors. Retrospective studies on LES for PPU have reported that the laparoscopic knotless suture repair using barbed suture material is an alternative, feasible, safe, simple, and non-inferior method. However, recommendation evidence on single port LES for PPU is unclear.